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Role of Robotics in Whipple's Surgery

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Role of Robotics in Whipple's Surgery WJOLS 10.5005/jp-journals-10007-1146 REVIEW ARTICLE Role of Robotics in Whipple’s Surgery Role of Robotics in Whipple’s Surgery B Srinivas ABSTRACT In computer-controlled systems, the surgeon uses a Whipple is one of the most demanding and complex surgeries computer to control the robotic arms and its end-effectors, of the abdomen. It is the most commonly performed operation though these systems can also still use telemanipulators for for pancreatic cancer, the fourth leading cause of cancer death their input. One advantage of using the computerized in the United States. For patients with benign as well as malignant pancreatic tumors, it is believed that the robotic method is that the surgeon does not have to be present, Whipple procedure will be a major improvement over the indeed the surgeon could be anywhere in the world, leading traditional procedure. The robotic surgery involves five small to the possibility for remote surgery. incisions (one to accommodate a miniature camera), rather than a large incision and separation, not cutting of muscles. HISTORY Keywords: Robotic Whipple’s surgery, Robotic surgery, Da Vinci Whipple’s surgery. • 1985: A robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.3,4 How to cite this article: Srinivas B. Role of Robotics in Whipple’s Surgery. World J Lap Surg 2012;5(1):39-45. • 1988: The PROBOT, developed at Imperial College London, was used to perform prostatic surgery. Source of support: Nil • 1992: The ROBODOC from Integrated Surgical Systems Conflict of interest: None declared was introduced into mill out precise fittings in the femur for hip replacement.9 INTRODUCTION • 1997: A reconnection of the fallopian tubes operation A robotic device is a powered, computer-controlled was performed successfully in Cleveland using manipulator with artificial sensing that can be reprogrammed ZEUS. to move and position tools to carry out a wide range of • May 1998: Dr Friedrich Wilhelm Mohr using the da tasks.1 Telemanipulators and robots were first developed Vinci surgical system performed the first robotically by the National Aeronautics and Space Administration assisted heart bypass. (NASA) for use in space exploration. In 1985, NASA • September 2010: The Eindhoven University of instituted a research program in telerobotics to develop the Technology announced the development of Sofie technology for the United States Space Program.2 surgical system, the first surgical robot to employ force The medical robotic systems of present generation are feedback. the brainchild of the United States Department of Defence’s The intuitive surgical introduced the da Vinci desire to decrease war casualties with the development of surgical system and computer motion with the AESOP ‘telerobotic surgery’. The ‘master-slave’ telemanipulator and the ZEUS robotic surgical system. (Intuitive surgical concept was developed for medical use in the early 1990s bought computer motion in 2003; ZEUS is no longer where the surgeon’s (master) manual movements were being actively marketed).5-7 transmitted to end-effector (slave) instruments at a remote Three main types of surgical robots available at present site. The field of surgical robotics has undergone massive are as follows: transformation since then and the future is even brighter.2 1. Supervisory-controlled Robotic Surgery Systems (e. g. Robotically-assisted surgery was developed to overcome the ROBODOC® system from CUREXO Technology the limitations of minimally invasive surgery. Corporation): It is the most automated surgical robots Methods of controlling the instruments in robotic available till date. Surgeons can plan their surgery surgery: preoperatively in a 3D virtual space and then execute 1. Telemanipulator the surgery exactly as planned in the operating theater. 2. Computer-controlled system 2. Shared-control Robotic Surgery Systems: These robots A telemanipulator is a remote manipulator that allows aid surgeons during surgery, but the human does most the surgeon to perform the normal movements associated of the work. with the surgery, while the robotic arms carry out those 3. Telesurgical devices: Here, the surgeon directs the movements using end-effectors and manipulators to perform motions of the robot, e.g. the da Vinci robotic system, the actual surgery on the patient. the ZEUS surgical system. World Journal of Laparoscopic Surgery, January-April 2012;5(1):39-45 39 B Srinivas The da Vinci surgical system comprises three AIM OF STUDY components: The aim of this review article is to appraise and to evaluate • A surgeon’s console, the present and future role of robotics in Whipple’s surgery. • A patient-side robotic cart with four arms manipulated The following parameters were evaluated: by the surgeon (one to control the camera and three to 1. Patient and disease factors manipulate instruments), and 2. Technical considerations • A high-definition 3D vision system. Articulating surgical 3. Operating time instruments are mounted on the robotic arms which are 4. Intra- and postoperative complications introduced into the body through cannulas. 5. Postoperative morbidity Three generations of da Vinci surgical systems have 6. Hospital stay developed so far:8 7. Cost-effectiveness 1. da Vinci surgical system (1999): It consists of three 8. Quality of life analysis. components: The viewing and control console, surgical arm unit (three or four arms depending on the model) MATERIALS AND METHODS and optical three-dimensional vision tower (Figs 1A to C). A literature search was performed using search engine 2. da Vinci S HD surgical system (2006): This second google, Springer, HighWire, Sages, IJA, PubMed, etc. and generation surgical robot is equipped with wide range the literature analyzed. of motion of robotic arms and extended length instruments, interactive video displays and touch screen KEYWORDS monitor. 3. da Vinci Si HD surgical system (2009): It has • da Vinci robotic system dual console capability to support training and • Robotic Whipple collaboration, advanced 3D HD visualization with up • Robotic pancreaticoduodenectomy to 10× magnification, ‘EndoWrist’® instrumentation • Robotic surgery with dexterity and range of motion more than the human • Minimally invasive surgery hand and ‘Intuitive® motion technology’(Figs 2A and B), • Pancreatectomy which replicates the experience of open surgery by • Pancreatic resection preserving natural eye-hand-instrument alignment.8 The • Pancreaticoduodenectomy new da Vinci HD SI released in April, 2009 currently • Whipple’s surgery. sells for $1.75 million. CARCINOMA OF THE PANCREAS AND SYNONYMS PERIAMPULLARY AREA • Robotic surgery Essentials of diagnosis: • Computer-assisted surgery • Obstructive jaundice (may be painless) • Robotically-assisted surgery. • Enlarged gallbladder (Courvoisier’s sign) A B C Figs 1A to C: (A) The da Vinci system surgeon console (B) The cart with three mounted surgical arms (C) joysticks with viewing ports in the console (courtesy: Intuitive Surgical Inc, Sunnyvale, CA) 40 JAYPEE WJOLS Role of Robotics in Whipple’s Surgery • Upper abdominal pain with radiation to back, weight IMAGING loss and thrombophlebitis are usually late mani- CT scan: A multiphase helical CT scan is the initial festations. diagnostic tool and detects a mass in more than 80% of Risk factors for pancreatic cancer: cases. Age • Endoscopic ultrasound • Obesity • PET scan • Tobacco use • MRI • Family history • ERCP • Heavy alcohol use • MRCP. • Chronic pancreatitis • Prior abdominal radiation WHIPPLE’S SURGERY • Previous H/O partial gastrectomy. Whipple’s surgery is done for: • Cancer of the head of the pancreas GENERAL CONSIDERATIONS • Cancer of the duodenum Ductal adenocarcinoma is the most common neoplasm of • Cholangiocarcinoma (cancer of the pancreatic end of the pancreas. Other neoplasms of pancreas include: the bile) • Mucinous cyst adenocarcinoma • Cancer of the ampulla • Serous cyst adenoma • Whipple operation may also sometimes be performed • Mucinous cyst adenoma for patients with benign (noncancerous) disorders such • Malignant exocrine tumors as chronic pancreatitis and benign tumors of the head • Benign exocrine tumors of the pancreas. • Endocrine – Gastrinoma Advantages of Robotic Whipple – Insulinoma. The robotic Whipple offers patients a minimally invasive Carcinomas involving the head of the pancreas, the option to the traditional surgeries for pancreatic cancer and ampulla of Vater, the distal common bile duct and the benign tumors of the pancreas and colon, resulting in the duodenum are considered together, because they are usually potential for: indistinguishable clinically; of these, carcinomas of the • Less pain pancreas constitute over 90%. About 75% are in the head • Shorter hospital stays and 25% in the body and tail of the organ. They comprise • Faster recovery times 2% of all cancers and 5% of cancer deaths. Risk factors • Minimized scarring include new-onset diabetes mellitus after the age of 45 years, • Blood loss occasionally heralds the onset of early pancreatic cancer. • Less complications. A B Figs 2A and B: (A) New generation robotic instruments have seven degrees of freedom as the human hand, (B) EndoWrist’® instrument from intuitive surgical (Courtesy: Intuitive Surgical Inc, Sunnyvale, CA) World Journal of Laparoscopic Surgery, January-April 2012;5(1):39-45 41 B Srinivas LIMITATIONS OF ROBOTIC-ASSISTED SURGERY • The presence of a replaced right hepatic artery and the position of the 1st jejunal vein (J1) branch, as it Patient safety in the event of
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